DISCLAIMER: The cases / examples on this blog have been anonymised to maintain confidentiality of patients. Cases have been acquired from various international hospitals and through other medical colleagues with the intention to teach through case examples.

Thursday, 21 February 2008

Today's discussion is slightly different. I would like to discuss my opinion on the transition from medical student to becoming a doctor.

I remember being a medical student and attending lectures to learn about diseases, pharmacology, anatomy, biochemistry and so on and so forth. The information in those lectures was excellent and provided the foundation of my knowledge of common diseases.

In part, I was also allowed to go to different locations for training outside the university for specialties such as surgery, paediatrics, obstetrics and gynaecology, general medicine, general (family) practice to name but a few.

In so doing, I was able to learn as a student how the information in the lectures and in the books bore relevance in the hospital system. As such, I soon learnt that the rare diagnoses such as Zollinger-Ellison Syndrome from gastrinoma are very rare, but of course, such rare diagnoses are what everyone remembers. However, the common things such as heart failure, its presentation, investigation and therapy may have only been covered in a single lecture with no emphasis on this being an important thing to know.

Hence, using the basic knowledge from medical school and seeing how it is applied in the real life scenario of the hospital system is really essential how to understand and make the transition from medical student to doctor.

One thing I always say is Common Things Are Common, and I often hear from medical students and junior doctors alike, rare diagnoses, which albeit are correct, are not the commonest presenting illness for the symptoms and signs.

How did I make the transition from medical student to doctor??

Well, I was always advised by my mentor, a famous Professor in Infectious Disease medicine, to see the patient and obtain the history and physical examination and then read about the problems in the textbooks, thereby reinforcing the medical problems with literature. This indeed was useful and I use such a method to this day. In fact, the patients are the best teachers. Going to the bedside and going through a detailed history in the correct order of how things occurred will in fact teach you a lot about the illness by itself. In so doing, the information obtained can then allow you to concentrate on areas of the physical examination that cause concern.

Then, by drawing together the positive elements of the clinical picture along with the pertinent negative symptoms e.g. no chest pain, no sputum, in a body systems review, allowed me to understand which diseases were not likely to be causing the problem.

By having a problem list from history and physical examination alone, I was then taught to consider the likeliest diagnoses from these problems e.g. central crushing chest pain, dyspnoea, diaphoresis, nausea and vomiting are more likely to be an AMI or unstable angina rather than Bornholm's disease from coxsackie virus.

It is all very good to use a medical list of causes, the one which I constructed is DIET IN HIM, an example case that I published last year maps out the different causes from the DIET IN HIM list for a particular patient problem. However, this is just the start!! One has to know the epidemiology of disease such as the age of onset, the likelihood in female or males e.g. SLE, how the disease usually presents and the salient features for diagnosis. Then one has to produce the differential diagnosis based on which is the best diagnosis to fit all the features and with less common ones below this.

Remember, this is based solely on history and physical examination alone.

In the UK, most patients admitted will been seen by the junior doctors who takes the history and physical at the bedside. There may be an ECG available and rarely have any blood tests been taken except if it is a referral from the Accident and Emergency (ER) department or another team. Then the junior doctor takes the blood tests and orders the radiological tests.

However, in the interim, whilst awaiting the results, treatment is usually commenced in anticipation of the results. Hence, treatment is not delayed waiting to see if you are right or wrong. How can this be done??

Well, it comes back to interpreting the history and physical examination. Patients with signs of heart failure get furosemide before the chest xray is performed with oxygen therapy. Patients with chest pain consistent with an ST elevation MI on ECG get the aspirin, heparin, oxygen, morphine, and thrombolysis before the CK and Troponins are available. Patients with signs of a tension pneumothorax get the needle inserted into the 2nd intercostal space in the mid-clavicular line before the CXR is taken. The patient with a good history of PE e.g. sudden onset pleuritic chest pain, cough, dyspnoea, hypoxaemia and a clear chest examination and Xray get heparin before the D-Dimer or spiral CT are performed.

The fact is, making a diagnosis based on history and physical examination is imperative. Without the proper history and poor physical examination skills, the ability to make a diagnosis can be delayed and then the reliance on machines to make the diagnosis for you increases and treatment for severe illnesses can be delayed resulting in adverse outcomes.

Problem Based Learning (PBL) using common presenting illnesses to teach how to understand differential diagnoses and which common diagnoses to consider is very important. This type of teaching is used for the famous MRCP exams in which limited data is provided and the likeliest diagnosis needs to be selected. The USMLE exams are similar in format as well. You see, patients do not present to you and say I have all of these symptoms and my diagnosis can only be X disease. There are many diseases that have overlap of symptoms and signs and the only thing that can separate them can be the timing of onset, epidemiology, sex predominance, location in the world, sexual history, so on and so on.

However, PBL is a classroom based idea and sets the mental framework about how to go about thinking of the patient problems. It is an entirely different scenario being tired and on-call at 4am and to be called to the ER to see a sick patient. This is where the use of bedside teaching comes in to play. By knowing which salient questions to ask as a discriminator to quickly get to the likely diagnosis can speed up the history taking and allows the doctor to already consider what treatments the patient is likely to require.

For example, the patient with the classical history of ischaemic chest pain is going to be questioned about the elements of the pain, its severity, its radiation, to ascertain if it is truly ischaemic or related to for example a dissecting aortic aneurysm because the treatments are different, the former being medical in most cases and the latter being emergency surgery!!

It is my opinion that training as a doctor is a vocation. When you become a doctor for the first time, you have just started on the long road to learning about diseases, their diagnosis and treatment. Medical school does not adequately prepare you for real life medicine. It neither prepares students about how to talk to patients or their families.

The best way to really make the transition is to see as many patients as possible as a student and really try and take a decent and comprehensive history including the Body Systems Review. The teaching of physical examination is really very much reliant on your teachers but you can also learn from some very good books that are available these days.

Try and practise Problem Based Learning. One UK book I would recommend is Rapid Review of Clinical Medicine (for MRCP) by Sharma and Kaushal and published by Manson Publishers. This book is available from Amazon.

Then, with this background of patients cases from real examples plus PBL examples, when you see a similar patient case in future, you should go through a similar process for the differential diagnosis and scale according to likelihood the most likely diagnosis and consider what further tests you would do and more importantly, what emergency treatments you will start.

Learn, learn, learn your medical emergencies e.g. treatment of AMI, PE, COPD, Asthma, Seizure etc.... There are many books available to do this, but I would strongly suggest you use one based on current evidence rather than on opinion.....

The ability to solve medical problems come from many years of experience and even senior doctors get it wrong on occasion because patients don't write the textbooks and doctors are human.